Provider Demographics
NPI:1750642633
Name:SHAW FAMILY MEDICAL, LLC
Entity Type:Organization
Organization Name:SHAW FAMILY MEDICAL, LLC
Other - Org Name:SHAW FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUGH-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-754-3301
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773-0299
Mailing Address - Country:US
Mailing Address - Phone:662-754-3301
Mailing Address - Fax:662-654-3304
Practice Address - Street 1:112 W PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773-8710
Practice Address - Country:US
Practice Address - Phone:662-754-3301
Practice Address - Fax:662-754-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center